Project Name: Date:   Facility 1     Facility’s Name:   Address: Phone:   City: State: Zip: Fax:   Type of Facility   Hospital Inpatient-21 Hospital Outpatient-22 Emergency Room-23 Ambulatory Surgery-24   Skilled Nursing Facility-31 Hospital Outpatient-22 Nursing Facility-32 Other:    Rehabilitation Facility (Outpat.)-62 Rehabilitation Facility (Inpat.)-61 Office-11     Facility 2     Facility’s Name:   Address: Phone:   City: State: Zip: Fax:   Type of Facility   Hospital Inpatient-21 Hospital Outpatient-22 Emergency Room-23 Ambulatory Surgery-24   Skilled Nursing Facility-31 Hospital Outpatient-22 Nursing Facility-32 Other:    Rehabilitation Facility (Outpat.)-62 Rehabilitation Facility (Inpat.)-61 Office-11     Facility 3     Facility’s Name:   Address: Phone:   City: State: Zip: Fax:   Type of Facility   Hospital Inpatient-21 Hospital Outpatient-22 Emergency Room-23 Ambulatory Surgery-24   Skilled Nursing Facility-31 Hospital Outpatient-22 Nursing Facility-32 Other:    Rehabilitation Facility (Outpat.)-62 Rehabilitation Facility (Inpat.)-61 Office-11     Facility 4     Facility’s Name:   Address: Phone:   City: State: Zip: Fax:   Type of Facility   Hospital Inpatient-21 Hospital Outpatient-22 Emergency Room-23 Ambulatory Surgery-24   Skilled Nursing Facility-31 Hospital Outpatient-22 Nursing Facility-32 Other:    Rehabilitation Facility (Outpat.)-62 Rehabilitation Facility (Inpat.)-61 Office-11     Facility 5     Facility’s Name:   Address: Phone:   City: State: Zip: Fax:   Type of Facility   Hospital Inpatient-21 Hospital Outpatient-22 Emergency Room-23 Ambulatory Surgery-24   Skilled Nursing Facility-31 Hospital Outpatient-22 Nursing Facility-32 Other:    Rehabilitation Facility (Outpat.)-62 Rehabilitation Facility (Inpat.)-61 Office-11     Facility 6     Facility’s Name:   Address: Phone:   City: State: Zip: Fax:   Type of Facility   Hospital Inpatient-21 Hospital Outpatient-22 Emergency Room-23 Ambulatory Surgery-24   Skilled Nursing Facility-31 Hospital Outpatient-22 Nursing Facility-32 Other:    Rehabilitation Facility (Outpat.)-62 Rehabilitation Facility (Inpat.)-61 Office-11     Facility 7     Facility’s Name:   Address: Phone:   City: State: Zip: Fax:   Type of Facility   Hospital Inpatient-21 Hospital Outpatient-22 Emergency Room-23 Ambulatory Surgery-24   Skilled Nursing Facility-31 Hospital Outpatient-22 Nursing Facility-32 Other:    Rehabilitation Facility (Outpat.)-62 Rehabilitation Facility (Inpat.)-61 Office-11     Facility 8     Facility’s Name:   Address: Phone:   City: State: Zip: Fax:   Type of Facility   Hospital Inpatient-21 Hospital Outpatient-22 Emergency Room-23 Ambulatory Surgery-24   Skilled Nursing Facility-31 Hospital Outpatient-22 Nursing Facility-32 Other:    Rehabilitation Facility (Outpat.)-62 Rehabilitation Facility (Inpat.)-61 Office-11